Medicaid & Gender Affirming Care: A Primer

Update on Medicaid Coverage of Gender-Affirming Health Services

Under Medicaid, states must cover certain mandatory benefits, such as inpatient and outpatient services, home health services, and family planning services. There aren’t specific federal requirements regarding coverage or exclusion of gender-affirming health care services as a category of Medicaid benefits, but there are rules regarding comparability that say “services must be equal in amount, duration, and scope for all beneficiaries within an eligibility group”.

Medicaid benefits are subject to Section 1557 of the Affordable Care Act which prohibits discrimination based on sex. The Biden Administration recently proposed a new rule on Section 1557 that explicitly states that sex-based protections to include sexual orientation and gender identity.

In a survey of states on coverage of sexual and reproductive health services conducted in Summer 2021, KFF and Health Management Associates asked states about coverage of five gender-affirming care services: 1) gender-affirming counseling; 2) hormones; 3) surgery; 4) voice and communication therapy; 5) fertility assistance for transgender enrollees.

Interestingly (given the nature of the previous administration) AHCCCS covers 3 of the 5 gender affirming care services when medically necessary (for adults): Gender affirming hormone therapy, gender affirming voice/communication therapy and mental health services. The two services not covered by AHCCCS are gender affirming surgery and fertility services.

The Full KFF report of the survey findings are posted at Update on Medicaid Coverage of Gender-Affirming Health Services | KFF.

Hobbs Issues Pair of Executive Orders: Expanding Coverage for Gender Affirming Care & Prohibiting State Support for Conversion Therapy

Governor Hobbs issued an Executive Order Tuesday that will allow state employees to access gender-affirming surgery. In a related Order, she ended any state involvement in “conversion therapy”.

One Order directs ADOA to remove a prohibition on state employee health plan coverage for gender-affirming surgery. That limitation was initiated in Ducey’s first term (2017). The Order also stops state agencies from cooperating with civil or criminal cases in other states where gender affirming care is banned.

See the Executive Orders

The other Order prohibits state agencies from promoting or supporting “conversion therapy,” a practice that IS NOT evidence-based that attempts to change a person’s sexual orientation or gender identity.

Note: AZPHA has a long history of supporting health equity including for those in the LGBTQ+ community. In 2021 AzPHA members approved this Resolution Eliminating of the Use of Conversion Therapy Practices for LGBTQ Individuals

FDA Advisory Committee Unanimously Recommends Moving to a Strictly Omicron-focused COVID Vaccine this Fall

FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) met on June 15, 2023, to discuss and make recommendations for SARS-CoV-2 strain(s) for updated COVID-19 vaccines for use in the United States beginning in the fall of 2023.

The committee unanimously voted that the vaccine composition be updated to a monovalent COVID-19 vaccine with an XBB-lineage of the Omicron variant for the 2023-2024 formulation of the COVID-19 vaccines for use beginning this fall. 

“Based on the totality of the evidence, FDA has advised manufacturers who will be updating their COVID-19 vaccines that they should develop vaccines with a monovalent XBB 1.5 composition.”

See: Vaccines and Related Biological Products Advisory Committee June 15, 2023 Meeting Announcement – 06/15/2023 | FDA

Legislative Session Summary PowerPoint & Webinar

It’s fair to say that the 2023 Legislative Session was like no other in Arizona history. A record number of bills were vetoed, yet a bipartisan budget was passed relatively quickly. Here’s a PowerPoint that briefly summarizes the session along with links to the actual bills themselves. 

You’ll see there were actually several good bills that passed including some important gains in the budget like a big infusion into the Housing Trust Fund and some funding to set up Teaching Health Centers to build more primary care residency slots in rural and underserved areas.

The bills that were harmful to public health were vetoed, but a couple of new ballot measures will be on the 2024 ballot that would be harmful -especially the referendum that would limit public health emergencies to just 30 days unless the legislature renews it in additional monthly increments (governors can’t veto legislative ballot referrals).

There were also many missed opportunities to improve public health and government accountability – good bills that either died in committee, failed on the floor, or were amended at the 11th hour to neuter them.

Here’s where you can See the Slide Deck summarizing those bills.

View Our Webinar Summarizing the 2023 Legislative Session
Passcode: 5=5FjjNC



Governor Hobbs Issues Reproductive Rights Executive Order 

Governor Hobbs issued an executive order last week which gives Attorney General Kris Mayes prosecutorial authority over any abortion prosecutions in Arizona – removing that authority from the various county attorneys in AZ.  

The Executive Order states that the AG “… shall assume duties with regard to any criminal prosecution of a medical provider or other entity or individual that is pending or brought in the future by the county attorney of any county” that is related to abortion care.

The order also prohibits state agencies (mostly ADHS and various Boards) from “... participating in or assisting an investigation of unlawful abortion procedures” (unless required by a court order) and states that Arizona won’t extradite anyone charged with abortion-related crimes in another state.

The Order also creates a new committee to study abortion access and provide recommendations to the governor. Here’s where you can read the Executive Order.

Note: This action will no doubt be court.

Cultivating Inclusion: A Free Health & Athlete Leadership Conference

Special Olympics Arizona would like to invite you to attend the inaugural “Cultivating Inclusion: A Health and Athlete Leadership Conference” on Saturday, August 5th at Desert Willow Conference Center in Phoenix. This conference is open to health professionals, health professional students, and SOAZ athletes.

Join us as we discuss the importance and workings of inclusive health and hear directly from those with intellectual and developmental disabilities about their lived experience during this interactive day. Registration is free and includes a continental breakfast, buffet lunch, and snack. Registration is open and will close July 31st, or when no more spots are available.

Click Here to Register

Special Olympics Arizona’s (SOAZ) goal is to empower Arizonans with intellectual disabilities to be healthy, productive, and respected members of society through SOAZ’s year-round sports training, competitions, and support program. SOAZ believes that all people – with or without intellectual and developmental disabilities (IDD) – should have equitable access to quality health care, education, and services in their communities and SOAZ aims to strengthen the capacity of health organizations, providers, educators, and influencers, to make policies, programming, services, research, trainings and funding streams inclusive and accommodating of people with IDD.

New Alzheimer’s Drug Provides Hope for Patients… but the Costs to Medicare Would be Extreme

There’s a fair amount of chatter in families who have a family member with Alzheimer’s now that a about a new (monoclonal antibody) drug developed by Eisai Co., Ltd. & Biogen Inc. An Advisory Committee to the Food and Drug Administration (FDA) unanimously endorsed the efficacy and clinical benefit of their drug, called lecanemab (Leqembi™, Eisai). The committee decision makes it very likely FDA will give full approval for the drug (a monoclonal antibody treatment) later this summer.

At that point, a huge debate will ignite about whether Medicare will cover the treatment and for whom.

For families and patients, the drug may slow progression of the disease in early-stage patients. However, this drug is not a cure, and it doesn’t make people get better, but it may slow down progression in very mild disease patients. Leqembi can cause swelling or bleeding in the brain, which means patients must receive periodic brain scans after starting treatment. The monoclonal antibodies are given intravenously every other week to remove amyloid from the brain. Amyloid plaques are a hallmark of Alzheimer’s, though many earlier drugs that targeted amyloid failed to slow down patients’ loss of mental abilities.

The stakes are high for everyone who pays Medicare payroll taxes and especially persons who already participate in Medicare, as the drug is so expensive. The potential number of patients so also large, meaning covering the drug could result in large premium increases for all Medicare patients and potentially even require a Medicare payroll tax increase.

The exact number of Medicare beneficiaries who meet the prescribing requirements for Leqembi is unknown and the take-up rate among eligible individuals is difficult to estimate. But, if 5% of the 6.7 adults in the US with Alzheimer’s disease take Leqembi at the annual list price of $26,500 it would cost Medicare Part B $8.9 billion to Medicare Part B every year. A 10% take-up rate would amount to $17.8 billion in higher spending.

From KFF: “Spending on Leqembi would be roughly equal to spending on the top 3 Part B drugs combined in 2021 based on the 5% take-up rate. At the 10% take-up rate, projected spending on this one drug alone would exceed spending on the top 10 Part B drugs in 2021 and would represent close to half of the $40 billion spent in total on the 600+ Part B covered drugs in 2021.”

New Alzheimer’s Drugs Spark Hope for Patients and Cost Concerns for Medicare | KFF

Higher Medicare Part B spending would likely lead to higher Medicare Part B premiums, which are set to cover roughly 25 percent of program costs. In the case of Aduhelm, the anticipation of substantially higher Medicare Part B spending due to coverage of that drug contributed to a 15% jump in the Part B premium between 2021 and 2022, an increase substantially above the norm. Medicare’s subsequent decision to limit coverage of Aduhelm contributed to a modest (3%) decline in the Part B premium for 2023.

At Leqembi’s current $26,500 list price, Medicare patients administered the drug would be responsible for more than $5,000 out of pocket each year, based on a 20% coinsurance requirement in traditional Medicare.

To address concerns about the effect of high-priced drugs on Medicare program spending, the Inflation Reduction Act requires Medicare to negotiate the price of top spending drugs, but manufacturers of biologic drug products like Leqembi would be exempt from having CMS-negotiated prices take effect for 13 years from the drug’s licensure date.

Assuming Leqembi receives full approval in July 2023 and Medicare coverage expands shortly thereafter, the drug’s manufacturers will have between now and 2036 to recoup investments in research and development and earn revenue from Medicare before possibly having negotiated pricing take effect.

While broader access to Leqembi could provide modest clinical benefits to older adults with mild cognitive impairment and mild dementia stage of Alzheimer’s disease, a significant increase in Medicare spending and premiums is a distinct possibility, and one that Medicare, patients, and taxpayers are likely to confront in the not-too-distant future.

Editorial Note: The issue with the price to Medicare for this drug highlights what will be an increasing problem for Medicare. The cost of new drugs times the number of people that will want them is becoming increasingly untenable under the current fiscal framework.

If you listen to the media and some politicians, you may have been led to believe the Medicare negotiation component of the Inflation Reduction Act took care of this problem IT DID NOT.

While earlier proposals (H.R. 3 and even the initial proposal in the IRA) did give good negotiating authority to Medicare the final version only gives very modest and delayed negotiating authority to Medicare. Senator Sinema was instrumental in stripping out the more meaningful parts of the bill, just sayin’.

See: More Meaningful Prescription Drug Price Reform That Could Have Been

Half Cent Sales Tax for Transportation in Maricopa County Still in Limbo 

The Governor & legislative leadership still haven’t come up with a compromise to send a Prop 400 transportation tax renewal proposal to Maricopa County voters. Last legislative session a clean proposal was passed by the legislature but was vetoed by Ducey. According to a decades-old law, the legislature has to approve the packages voters are allowed to consider. That’s not the case in any of the other counties.

A proposal has been worked out by the Maricopa Association of Governments that would dedicate 40% of the tax (if approved by voters) to freeways, 22% for big roads and 38% for transit, and 3.5% for rehabilitation of the existing light rail system.

The hang up on getting a deal is with that 3.5% for light rail rehab. The as of yet released legislative proposal (R) would lower transit funding to 36.5% instead of 40%… the difference being the 3.5% for rail.  A different one separates Prop 400 into two ballot questions. The first would dedicate $0.43 of the half-cent sales tax to freeways, arterials, and buses; the second question would distribute the remaining $0.07 to mass transit. Voters would then vote on those two separately.